"AOS Review FY2 Von"
Circumstance -- Reviewed at the request of Dr. Smith following an outpatient clinic review to investigate persistent abdominal pain.
Background -- Patient with a history of Stage III colon cancer, diagnosed in 2021. Completed adjuvant chemotherapy with FOLFOX in 2021-2022. Currently in remission.
Presenting complaint -- 68-year-old male with a 2-week history of intermittent, crampy abdominal pain.
History of presenting complaint--
* Pain: Described as intermittent, crampy abdominal pain, located in the lower abdomen.
* Onset: Began approximately two weeks ago, initially mild, now increasing in severity.
* Character: Cramping, colicky.
* Radiation: No radiation.
* Associated Symptoms: Associated with bloating and occasional nausea. No vomiting, fever, or change in bowel habits.
* Timing: Pain occurs in episodes, lasting 30-60 minutes, several times a day.
* Exacerbating Factors: Worsened after meals.
* Severity: Rated 4/10 at its worst.
* No recent changes in medications.
* No recent travel or sick contacts.
Past Medical History --
1. Hypertension, managed with Lisinopril 10mg daily.
2. Hyperlipidemia, managed with Atorvastatin 20mg daily.
Medication History --
1. Lisinopril 10mg, once daily.
2. Atorvastatin 20mg, once daily.
3. Paracetamol 1g, as required for pain.
Social History --
* Non-smoker. Drinks alcohol occasionally, approximately 1-2 units per week. No recreational drug use.
* Lives at home with his wife. Independent in all activities of daily living. WHO performance status 1.
* Retired accountant. No known occupational hazards.
On examination --
* Abdomen: Soft, non-tender on light palpation. Mild tenderness in the lower abdomen on deep palpation. No guarding or rigidity. Bowel sounds present.
* No palpable masses or organomegaly.
* No lymphadenopathy.
Impression --
PLAN
1. Bloods.
2. CT Abdomen and Pelvis with IV contrast to rule out obstruction or recurrence.
3. Review imaging results and discuss with the patient.
4. Follow up in clinic in 2 weeks.
"AOS Review FY2 Von"
Circumstance -- (Include the circumstance if possible as to why the patient is reviewed at this very opportunity. For example, asked to see patient by Dr X after review in outpatient clinic to r/o obstruction)
Background --
(To mention patient's oncological background and the treatment that they have received, only include information from the transcript or clinical notes for this section if this is new/additional information to the context/background that has not been manually included or in the contextual notes. If background is available in the contextual notes, copy in verbatim.)
Presenting complaint --
(Mention the patient's presenting complaint in a catchy, succinct way including their age, gender and their duration of their presenting complaint that would allude to a set of management. For example, 87F 3/7 hx of sudden onset 10/10 headache, potentially alluding a set of management typically associated with ruling out a subarachnoid haemorrhage given their sudden onset headache, ruling out giant cell arteritis given their age, gender, and headache. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History of presenting complaint--
(Mention in the first paragraph a detailed history of the patient's various complaints. Format known presentations in styles classically taught at medical school that are typically associated with each classical presenting symptoms. For example, for pain, utillise the format SOCRATES, standing for -- Site, Onset, Character, Radiation, Associated Symptoms, Timing, Exacerbating Factors, Severity. For falls, e.g Symptoms pre-fall, during the fall, and post-fall. The first paragraph should include negative symptoms that would rule out the red-flag conditions that are typically associated with classical presenting complaints. Focus heavily on the timing course of the disease, the timing associated with the severity of the symptoms, and the timing with associated symptoms as it will better hint towards the underlying diagnosis. A good timeline is important. If the timing of any chemo/radio/immunotherapy/SACT/oncological surgery/interventions/new medications/any other iatrogenic interventions are mentioned, place a strong emphasis when generating the notes as it will place patient with an oncological background into context. Format the first paragraph with bullet points; indent supplemental details to major relevant symptoms/details. The second paragraph should contain any supplement information that would reenforce the most likely diagnosis or to rule out any red-flags conditions that the presenting complaints strongly suggests e.g. mentioning that the severity of the headache actually fluctuates from 1/10 to 10/10 in a patient presenting with sudden onset headache. Format the second paragraph with bullet points. The third paragraph should contain a brief systems review. Include all negative symptoms elucidated. Format above with bullet points and indent if related. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Past Medical History --
(Do not include oncological history. Include any other past medical history otherwise not pre-populated, directed, or supplanted by myself at a later stage. Include all past medical history mentioned, including starting on specialist medications e.g. Prednisolone or methotrexate for Rheumatoid Arthritis. Do not include oncological treatments otherwise mention in the background section. Format this paragraph with numbered bullet points. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medication History --
(Include medications that the patient mentions that they are currently taking in the following format -- drug name, dose, timing. Only include route if not per oral. Do not include oral or intravenous chemo/immunotherapy unless otherwise not stated. Format this paragraph this paragraph with numbered bullet points. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social History --
(include in the following format with the amount of information available. Include in the 1st paragraph-- Smoking history, alcohol history, recreational drug history. In the second paragraph -- living situation, WHO performance status, how they perform their ADLs, baseline mobility, baseline cognition. In the third paragraph -- Occupation/previous occupations, any occupational hazards including but not limited to e.g. heavy chemical exposure, asbestos exposure etc. only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
On examination --
(Include all findings with regards to the physical observation of the patient and the examination findings. Do not include if the patient mentions their subjective views. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Impression -- (to leave empty)
PLAN
1. (fill in as best. Abbreviate blood tests to "bloods"; This will imply the following blood tests -- FBC, Us and Es, LFTs, Bone profile, CRP, Phosphate, Magnesium. Use the following format if a specific blood test is taken in addition to the the above panel of bloods e.g. beta-d-glucan -- "Bloods including Beta d glucan".)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)